MEDICARE: ST. MARY'S PLACE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251S00000X	Community/Behavioral Health Agency
2	253J00000X	Foster Care Agency
3	101YP2500X	Professional Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275307266
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MARY'S PLACE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1838
Second Line	:
City	:	ALIEF
State	:	TX
Zip	:	77411-1838
Country	:	US
Telephone Number	:	832-894-9359
Fax Number	:

Provider Business Practice Location Address
First Line	:	3707 CYPRESS CREEK PKWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77068-3526
Country	:	US
Telephone Number	:	832-894-9359
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KIMBERLY CELESTE BASS
Credential	:	MA, LPC, LCDC, LSOTP
Telephone Number	:	832-894-9359

Provider Enumeration Date	:	11/09/2023
Last Update Date	:	11/09/2023

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